Sexual intimacy after Prostate Cancer

Treatment of prostate cancer, the most common type of cancer in men, usually has a list of negative side effects. Besides erectile dysfunction and urinary incontinence, many men also suffer from dry ejaculation, leakage of urine with orgasm, penile shrinkage, and bowel dysfunction. The impact of these physical effects on the sexual life of the men and their partners is in many cases devastating. It is true that some couples are able to adjust well to the changes in the sexual functioning of the person with cancer. For many others, however, cancer treatments bring a significant disruption to their sexual intimacy.

Once men are faced with the diagnosis of prostate cancer, the first challenge is to make an informed decision about the treatment. Making an appropriate decision is often problematic, because the information about the effectiveness and the side effects of the different options is not always conclusive. This explains the results of the mail-out survey published by Clark and colleagues in 2003. According to these authors, 24% of the 349 men surveyed, who had been treated for prostate cancer between one and two years prior to the survey, reported that they were poorly informed about the treatment and 16% regretted the option they made.

This study also highlights some important psychological and emotional aspects attached to the treatment decision. One particular issue is the lack of power some men felt when talking to their doctors. In particular, some of the men felt a lack of communication with their physicians, who seemed to have already made the best and most adequate treatment choice for their patient without even considering a more detailed discussion with him. However, even receiving comprehensive and extensive information, some men still might underestimate the severity of the side effects. It is critical, therefore, to be well-informed about the possible outcomes of the treatment. The best way to keep realistic expectations is to obtain sound and reliable information when talking to your doctor, but it is also important to make connections with other people who have lived through similar experiences. Visiting reliable online forums, such as “The Cancer Forums” (www.cancerforums.net) could be useful to share information with others who are further down the road. The connection with other men can help the couple cope better with the stress of managing the illness.

It is true that many men are very reluctant to disclose their illness experience with others. In a series of interviews conducted by Ross E. Gray and colleagues, from the University of Toronto, men with prostate cancer show different degrees in their willingness to talk about the effects of the illness and its treatment. Whereas for some men was important to connect to other prostate cancer patients, the majority felt reluctant to overtly explain their experience. The reasons for keeping the illness as a private issue are related to the social attitudes that define what it means to be a man. Showing autonomy, control, and power over the illness are expected male attitudes, as well as giving the impression of not needing any emotional support, the tendency to avoid and to negate the threat of illness and its stigmatization, and the desire to preserve the work environment.

All of these factors are connected to the general social conception of man as a capable and independent human being. Prostate cancer threatens the idealized masculine image in our western culture. A central aspect of this ideal of masculinity is the phallus (penis). As Beck and colleagues reminds us, “the penis, including its size and performance, is a strong indicator of masculinity in Western culture. To be considered masculine, a man’s penis should be long, have a large circumference, be capable of instantaneous erections, and have the ability to produce explosive orgasms” (Beck et al al., 2009, 138). In this cultural context, it is easy to see how a man’s identity can get seriously compromised when facing prostate cancer treatment. Treated men are likely to feel dependent on others, weak, unable to be in control of their own body and to perform sexually, according to the conventional standards centered in erection and penetration. The effect of this threat to masculinity is clearly manifested in the changing dynamics in the sexual intimacy with his partner(s).

The radical changes in sexual intimacy after prostate treatment not only affect the person with prostate cancer, but also the other member of the couple. In fact, recent studies on sexual functioning of heterosexual couples indicate that the sexual dysfunction in the male partner is correlated with the sexual dysfunction in the female partner. In one study conducted in 2004, researchers found lower levels of sexual arousal, lubrication, orgasm, satisfaction, and freedom from pain in women whose partners suffered from erectile dysfunction (Çayan et al., 2004).

What emerges from these studies is that sexuality is not an individual experience, but a complex social construction involving more than the person affected by the illness. Any change in sexual functioning of one member of the couple is to be surely to significantly transform the intimate sexual relationship, and, consequently, modify the dynamics of the couple. Indeed, the experience of cancer may shape the way the two people communicate and negotiate other areas of the relationship, such as their roles in the couple, their finances, their lifestyle, their future plans, or their jobs.

Confronted with the prospect of battling cancer, the important role that sexuality plays in the person’s life, and, in particular in the male´s identity, is often understated by the medical providers. For the men, however, the modification in their sexuality has a tremendous impact in their selves. In fact, data from surveys reveal that men treated for prostate cancer report more problems with sexual intimacy, sexual confidence, and masculine self-esteem than men without this health condition. Relatedly, many men acknowledge that the termination or drastic alteration of their sexual lives was the most significant event after treatment for prostate cancer (Beck et al., 2009)

Among the possible negative effects of the treatments, erectile dysfunction is by far the major problem. This concern with erection ability explains that almost 59% of affected men try to achieve sexual intercourse by using assistive aids. Some of the best-known assistive aids are oral medications such as Viagra, Levitra or Cialis; penile injections of synthetic vasoactive drugs, such as Tri-Mix; vacuum devices; or permanent penile prostheses. These aids are very useful, but almost 50% of the men stop using them eventually. Only 30% of the men were still relying on the assistive aids 4.5 years after their treatment.

In many cases, men start with the noninvasive aids, such as the oral medications, although the most invasives ones, such as penile intracavernous injections and prostheses, have the highest rates of success. Men who try more than one aid have also better chances of successfully treating erectile dysfunction. The problem with the use of assistive aids is that many couples feel that sex with these devices becomes more unnatural, less spontaneous and more awkward. There are, however, several factors that can contribute to the successful use of assistive aids. One big factor is each partner’s motivation and strong desire to regain and maintain erectile functioning. Another significant factor is being in a relationship. Having a stable partner increases the motivation to try assistive aids, particularly if the partner is in good sexual health and is younger in age. Also, initiating a new relationship is a strong motivational factor to use assistive aids.

Certainly, the use of sexual devices can be intimidating at first, or can make couples feel less erotic. More emphasis and time dedicated to foreplay and a more relaxed attitude toward penetration and orgasm can help the couple to rebuild their sexual intimacy, and obtain pleasure. The assistive aids target the sexual dysfunction, and can be effective treating it, but they have to be combined with interventions directed to solve other issues that might hinder sexuality, such as anxiety, poor physical health of the partner, problems of communication within the couple, or life stressors that diminish sexual desire.

To make the best of the assistive aids, it is important to have realistic expectations about the extent to which they can be instrumental in restoring sexuality after prostate cancer treatment. Although the majority of couples at the beginning are very hopeful and feel strongly encouraged to introduce them in their sexual life, many get disappointed with the results and experience failure over time.

As Beck et al. (2009) explained, the men often report that they did not anticipate how difficult it would be to use them. Sexual counseling can be a critical aid to help couples navigate through the path of rebuilding sexuality. Sexual counseling can help to improve the partners’ communicative skills, facilitating the dynamics of being open and straighforward about each person’s own needs, desires, fears, and frustrations. Sexual therapy can also provide the safe space to explore new facets in the couple’s sexual life.

Sources:

Beck, A.M., Robinson, J.W., Carlson, L.E. (2009). Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. Urologic Oncology: Seminars and Original Investigations, 27, 137–143.